Plurality, gender, and mental health

Guide for therapists interacting with transgender clients

Introduction

We are a transgender individual who has been diagnosed with dissociative identity disorder. We identify as plural (more than one of us sharing the same brain and body) and genderfluid (our gender varies between gender neutral and female). We have navigated the mental health system both to gain access to trans healthcare and to process childhood trauma. Our own experience as well as the experiences of friends has been that being trans complicates processing childhood trauma primarily due to many therapists not having a deep understanding of etiquette for interacting with trans people. We are writing this in hopes that trans people will be able to show it to their therapists to reduce the chance that preventable errors destroy a therapeutic alliance.

A note on terminology

We have chosen to use terminology from the dissociative identity (DID) literature because this is the most well known terminology in the medical community. Some people, including ourselves, prefer different terminology, but in the interest of making this article accessible, we use the most readily understood terminology.

Guidelines

Do not make assumptions

Explicit communication without assumptions is incredibly important for therapy of any type. It is doubly important when discussing topics which relate to trans issues. Trans people face a large number of obstacles when navigating this world, including both people who are actively hostile and people who say harmful things out of ignorance. Everything you do will be pattern matched against the behaviors of those who are have harmed trans people in the past, intentionally or unintentionally. If you are uncertain, ask.

You will make mistakes

No matter how hard you try or how much you understand about being trans, you will make mistakes. Even if you are trans and have a deep understanding of the problems the trans community faces and your own experience to draw on, you will still make mistakes. We are deeply involved in the trans community and interact with many trans people every day. We have our own experiences to draw from and hear the tales of other trans people on a daily basis. Even with all this knowledge and experience to draw from, we still make mistakes. Making mistakes is expected and is perfectly ok so long as you use them as learning opportunities and do what you can to avoid making the mistake again.

When you make a mistake, apologize

After you apologize, ask your client if they are comfortable and have the energy to explain why that behavior was problematic. Be understanding if they cannot or do not wish to perform this education, and understand that they are going above and beyond what is required of them if they do choose to perform education. Do not explain what your intention was. There are a large number of reasons why simply saying “I’m sorry” and listening is better than trying to explain your intentions. Here are a few of them:

Explaining your intentions will often be interpreted as trying to justify your actions.

Explaining why you performed an action which hurt your client transforms the conversation to be about you rather than about your client. In any instance where an action makes someone feel hurt, the focus should be on the individual experiencing pain.

Explaining your intentions can make it appear you are focusing on asking for forgiveness.

Directing the discussion to the mistake is an implicit request to discuss this further. By this point, your client is already feeling hurt and you should acquire explicit consent before attempting to continue discussing a sensitive topic.

In many cases, the hurtful action will be perceived as a boundary violation. On the extreme end, if a boundary violation is followed by an explanation of why the boundary violation is justified or why it is is your client’s best interest, the therapeutic alliance will be broken.

If you feel a strong desire to explain why you said what you did, ask your client if it would be helpful if you explained why you performed that action. If they say no, accept the answer and ask if there is anything you could do to help them. If they say yes, carefully approach the conversation and do repeated check-ins on whether they are ok. Since this must be approached with extreme sensitivity, anything other than a clear yes should be interpreted as an indication the topic should be changed.

Do not dismiss your client’s concerns

Your clients may raise concerns related to gender which you may not understand at first. A common, but unfortunate initial reaction when this happens is to give a response which dismisses the concerns. Initial dismissiveness can do damage to a therapeutic alliance even if it is followed by understanding and an apology. Approach concerns raised which you do not understand with curiosity and ask for material you can read to better understand your client’s concerns. Although it is possible to have your client educate your directly, every bit of energy expended on education puts strain on the therapeutic relationship (and will put strain on any relationship between two people).

Do not reply to concerns with “but my other trans clients did not have a problem with this”

Every member of a group is unique and will have varying responses to insensitive comments. Trans people will react strongly to different subsets of transphobic comments. Just because one trans person (or 10 trans people) is ok with something doesn’t mean everyone will be. If a trans person raises an issue with something you said, don’t try and justify it by claiming your other trans clients did not have a problem with it.

Gender is not the same as appearance

There is a misconception many people have that being female requires you to wear certain clothes. Therapists who work with trans people have a long history of requiring trans people to wear dresses to prove they are actually trans. This is changing with time, but many people still equate appearance with gender. Gender and appearance both come on a spectrum from strongly masculine to androgynous and to strongly feminine. It is possible for someone who is female to dress androgynously. It is possible for someone who is non-binary (is neither male nor female) to dress femininely. Understand that gender and appearance are separate. It is possible for someone who is male to have a feminine leaning wardrobe.

Interactions with the medical community trying to get medically necessary care are often traumatic in and of themselves

Many trans people have been denied care when they attempt to seek hormone replacement therapy (HRT) or surgery. Even in 2016, some therapists require trans women to go through a hazing ritual of wearing dresses for a year to start HRT. Other people end up with a therapist who does not want to write them a letter and uses moving goalposts to delay it indefinitely. Trans men often end up in a scenario where they must say they imagine having sex with a penis and must tell stories about an increased sex drive to fulfill masculine stereotypes to be able to access hormones. We personally had a psychiatrist who gave many reasons he did not want to write us a letter and eventually told us he believed we “should not be allowed to get surgery.” The three months it took us to get a second surgery letter were traumatic and for many months after surgery, we had flashbacks to our letter appointment with a different psychiatrist. Unfortunately, these experiences are not uncommon and many trans people have traumas from trying to navigate the healthcare system. Be aware of this and recognize that any statements you make related to gender or transitioning can tie into past traumas. Topics related to gender should be handled with the same level of care and gentleness as topics related to childhood abuse.

If you refuse to write an HRT/surgery letter, the therapeutic alliance will be broken.

A part of your job as a therapist is to help people navigate the healthcare system. For trans people, this involves writing letters confirming your client’s mental health is sufficiently good to access HRT and surgery. If you refuse to write these letters, because you don’t write evaluative letters, because you don’t believe you should have to write these letters, because you do not believe your client should be allowed to get surgery, or for any other reason, the therapeutic alliance will be broken. If you are unwilling to help your client gain access to medically necessary care, then you have made yourself into an obstacle to getting care. It is completely reasonable for a trans person to ask before their first appointment whether you have ever written an HRT/surgery letter before and whether you have ever refused to write a client a letter. If you truly do not want to write HRT/surgery letters for trans people, you should let prospective clients know this before therapy begins so they can determine whether this is compatible with their needs.

Do not comment on whether a client “passes” or what gender you perceive them as without explicit permission

Rather than being a compliment, this reveals you are evaluating your client along this axis. There is a lot of gatekeeping in the medical community based on appearance (ie. trans women expected to wear dresses to get medications) so this can immediately tie back into past traumas.

Never ask for a trans person’s birth name and never use their birth pronouns

Most trans people never identified with their birth name and birth pronouns. Many trans people have to fight long and hard for the people in their life to use their new name and pronouns after they transition. This is especially difficult with parents who have become used to using the name they assigned their child at birth and require a long time to break that habit. For others, their parents are actively hostile and attempt to block their transition in any way they can. Once transition has started, hostile parents and others often continue to use the trans person’s birth name in an effort to deny their trans identity. If you ask for someone’s birth name or use their birth pronouns to refer to them, you will be immediately pattern matched against people who actively try to deny trans people their gender identity and the therapeutic alliance will be severely damaged.

Ask what past selves should be referred to, both name and pronouns

note: this section is primarily written for therapy related to dissociative identity disorder

When speaking with child alters or child parts, ask what name and pronoun they wish to go by. In the past, we have had a therapist learn our birth name then later ask “is there any space for [birth name] [in your system]?” when referring to our past selves. This immediately damaged the therapeutic alliance which had taken months to build. The only way it could have been salvaged was with a strong apology and a promise to never use our birth name again. While seeing a different therapist, our partner was asked for their birth name. When they had a child part come out during therapy, their therapist referred to the child part by their birth name. This brings up strong associations with people who actively try to deny the identities of trans people, often trans people’s own families. Performing an action which so closely mirrors past traumas must be followed by a strong apology and a promise to never do it again if the therapeutic alliance is to be salvaged.

Neither childhood trauma nor multiplicity should not prevent a trans person from accessing surgery or HRT

note: this section is primarily written for therapy related to dissociative identity disorder

Many people who wish to deny trans identities point to childhood trauma and use that to argue that the trans person is “confused” about their identity. The generalized version of this is to look for any excuse to claim a trans person doesn’t know what is best for themselves because of any comorbid condition. Trans people spend a long time questioning their identity before they are willing to reveal this to any medical professional. If someone says they are trans, they are trans. Do not attempt to deny the identity of a trans person because they are multiple or for any other reason. Furthermore, recognize that trans people are competent and can make their own medical decisions even if they are multiple or have a history of childhood trauma. Neither childhood trauma nor multiplicity should not prevent a trans person from accessing transition related medical care. In particular, do not refuse to write your client a HRT/surgery letter because they are multiple or have a history of childhood trauma.

Do not repeatedly try to find a causal relationship between your client’s trans status and every other issue they work on with you

Not every issue a client has is related to gender. If you continue to try to connect issues to gender and are wrong, you will deeply annoy your clients. If you try to connect issues to gender and are right, your client may not be ready to see the connection. Even if many issue are connected to gender, these issues are best explored when your client is ready. Exploring gender and connected issues is a multi year process involving internalized transphobia, relations with others, and is not a simple process. Let your client explore what issues are related to identity at their own pace and even if you think an issue is directly related to gender, it may be best to wait until they bring it up themselves. Bringing up a gender related topic before your client is ready can harm the therapeutic alliance and cause them to react negatively even if your connection is correct.

Final thoughts

When interacting with trans clients, you are not just working against past histories, you are working with the entire history of the trans community and ways others are harmful to trans people. Even if your intentions are wonderful, your actions must be considered in the broader scope of society. Actions which are harmless in isolation can destroy a theraputic alliance if it parallels actions other take while being actively harmful to trans people. For this reason, topics related to gender should be approached very carefully and with special attention paid to ensure you do not retraumatize a client.